Our letter was written in response to the article by M.R. Young et al. titled "Factors Associated With Uptake of Infant Male Circumcision for HIV Prevention in Western Kenya". An abstract and other information regarding the Young paper can be found at http://www.ncbi.nlm.nih.gov/pubmed/22711723. A PDF of the Young article can be found here.

Steven Svoboda
ARC

Financially, Ethically and Legally, Circumcision is Unsuitable to Combat AIDS and HIV

We are concerned by the inexplicable advocacy for male circumcision that Young et al. reinforce in their recent paper. The authors ignore numerous problems, including substantial ethical and legal issues, with the proposal for mass circumcision of Africans as an asserted HIV preventive.

The “drawback” of a “lengthy interval” between circumcision of an infant and the asserted benefit mentioned by the authors qualifies as an impressive understatement. For the past 150 years, circumcision has been a “cure” in search of a disease to treat. A program to circumcise infants in Africa is rendered sinister by its colonialist focus on ostensibly enlightened developed world practitioners “saving” African males from their own sexuality by cutting their bodies.

Such a program clearly violates our cherished ethical and legal values. In 1891, the United States Supreme Court recognized the right of all citizens to bodily integrity and self-determination. No right is held more sacred or is more carefully guarded by common law than the right of every individual to the possession and control of his own person free from all restraints or interference of others.[1] Joel Feinberg argues for the child’s right to an open future,[2] and the British Medical Association recommends prioritizing options that maximize the patient’s future opportunities and choices.[3]

Valid permission for a medical procedure has three elements: disclosure, capacity, and voluntariness. Voluntariness is absent from the campaigns to coerce adult African males to be circumcised. Moreover, children are incapable of granting consent. According to the American Academy of Pediatrics, parental permission for medical intervention on children is authorized only in situations of clear and immediate medical necessity, such as disease, trauma, or deformity.[4] For non-essential treatments—such as neonatal circumcision—that can be deferred without loss of efficacy, the physician and family must wait until the child is old enough to consent. Judging by the low adult circumcision rates (even in the US where it is much more common than anywhere else in the developed world) most will hang onto what they have.

Because parents lack the power to give permission for prophylactic amputation from their children of healthy tissue, and because neonatal circumcision has no universally recognized medical benefit, parental permission for the procedure is not effective.

Loss of function of the intact penis is an obvious and important issue, yet it has not been adequately addressed in the rush to circumcise. Moreover, recently created FGM “clinics” demonstrate that the demand for male circumcision may translate into an increased demand for female circumcision. Men’s false sense of security following circumcision will lead to a decrease in condom use and may endanger women.

Portrayals of circumcision as pain-free, cost-free, and complication-free fly in the face of reality. The rate of complications of circumcision performed in Africa is extremely high.[5] Little or no evidence exists that circumcision is a better option than consistent condom use, aggressive surveillance and treatment of STIs, or treatment of HIV with anti-retroviral therapy. Cost analysis shows that the asserted benefits account for only 24% of the lifetime costs. Any program for mass circumcision will undermine condom use and would divert funds to a more expensive, less effective intervention.

Any responsible recommendation of universal circumcision must grapple with grave issues: 1) The proposed intervention must be compared to other interventions for efficacy, cost effectiveness, and complications. 2) The surgical complications of the procedure are probably much higher in developing nations. 3) The loss of function and the benefits of the intact penis. 4) The questionable propriety of removing healthy, highly erogenous tissue from non-consenting minors to “protect” them, based on speculation about their future sexual behavior, from a disease that may not exist when they reach sexual maturity. 5) No proven biological basis exists for the asserted connection.

Mass circumcision as a preventive for HIV in developing countries is difficult to justify. Medical organizations around the world, including American organizations, unanimously refuse to endorse routine male circumcision. Studies claiming to support the mass circumcision program suffer from serious methodological and ethical flaws. Even if valid, such a proposal cannot ethically or legally be applied to the developed world.

Medicine must ally itself with scientifically proven practices within the dictates of medical ethics, human rights, and law. Circumcision, even as portrayed by its advocates, is much less cost-effective than other proven interventions and thus does not belong in a discussion of simple interventions to prevent HIV infection.